Consensus achievement of leadership,organisational and individual factors that influence safety climate: Implications for nursing management

Aim

To validate a framework of factors that influence the relationship of transformational leadership and safety climate, and to enable testing of safety chain factors by generating hypotheses regarding their mediating and moderating effects.

Background

Understanding the patient safety chain and mechanisms by which leaders affect a strong climate of safety is essential to transformational leadership practice, education, and research.

Methods

A systematic review of leadership and safety literature was used to develop an organising framework of factors proposed to influence the climate of safety. A panel of 25 international experts in leadership and safety engaged a three‐round modified Delphi study with Likert‐scored surveys.

Results

Eighty per cent of participating experts from six countries were retained to the final survey round. Consensus (>66% agreement) was achieved on 40 factors believed to influence safety climate in the acute care setting.

Conclusions

Consensus regarding specific factors that play important roles in an organisation's climate of safety can be reached. Generally, the demonstration of leadership commitment to safety is key to cultivating a culture of patient safety.

Implications for Nursing Management

Transformational nurse leaders should consider and employ all three categories of factors in daily leadership activities and decision‐making to drive a strong climate of patient safety.     

Clinical leadership: using observations of care to focus risk management and quality improvement activities in the clinical setting

In an era when patient safety and quality of care are a daily concern for health care professionals, it is important for nurse managers and other clinical leaders to have a repertoire of skills and interventions that can be used to motivate and engage clinical teams in risk assessment and continuous quality improvement at the level of patient care delivery. This paper describes how a cohort of clinical leaders who were undertaking a leadership development program used a relatively simple, patient-focused intervention called the 'observation of care' to help focus the clinical team's attention on areas for improvement within the clinical setting. The main quality and safety themes arising out of the observations that were undertaken by the Clinical Leaders (CLs) were related to the environment, occupational health and safety, communication and team function, clinical practice and patient care. The observations of care also provided the CLs with many opportunities to acknowledge and celebrate exemplary practice as it was observed as a means of enhancing the development of a quality and safety culture within the clinical setting. The 'observation of care' intervention can be used by Clinical Leader's to engage and motivate clinical teams to focus on continuously improving the safety and quality of their own work environment and the care delivered to patients within that environment.     

A Leadership Challenge: Staff Nurse Perceptions After an Organizational TeamSTEPPS Initiative

The purpose of this study was to measure RNs' perceptions of teamwork skills and behaviors in their work environment during a multiphase multisite nursing organizational teamwork development initiative. Teamwork is essential for patient safety in healthcare organizations and nursing teams. Organizational development supporting effective teamwork should include a just culture, engaged leadership, and teamwork training. A cross-sectional survey study of bedside RNs was conducted in one 5-hospital healthcare system after a TeamSTEPPS teamwork training initiative. TeamSTEPPS teamwork training related to improved RN perceptions of leadership. Initiatives to align the perspectives and teamwork efforts of leaders and bedside nurses are indicated and should involve charge nurses in the design.     

Answering the Wake-Up Call to Nurse Leaders: Five Practices to Restore Psychological Safety After the Vaught Case

The criminal prosecution of RaDonda Vaught shook the nursing world and impacted a stressed, disengaged, and dwindling, post-pandemic nursing workforce. As a result, it is critical for nurse leaders to ensure that psychological safety permeates the work environment because it is a central force for high performing teams and a culture of safety. This article proposes 5 specific and targeted leadership practices to successfully navigate organizational stress, restore trust, and ensure psychological safety in the workforce.     

Framework for patient safety, part 1: culture as an imperative

Nurse leaders play a critical role in patient safety. They are essential in building a culture of safety and engineering resilience into workflows and patient care processes enabling healthcare organizations to progress toward high reliability. In part 1 of this 2-part series, the authors discuss the critical nature of a safety culture: why trust and respect lead to teamwork and collaboration in preventing serious safety events. Part 2 will introduce the emerging healthcare concept of high reliability, described through examples of health systems that have successfully adapted models from other industries. Use of technology and other advancements provides a context for advancing patient safety. Aligning culture and engineering technology for safety, when coupled with effective leadership, can provide a long-term approach for safe and effective care.     

Use of video-feedback, reflection, and interactive analysis to improve nurse leadership practices

The chronic shortage of registered nurses (RNs) affects patient safety and health care quality. Many factors affect the RN shortage in the workforce, including negative work environments, exacerbated by ineffective leadership approaches. Improvements in the use of relationship-based leadership approaches lead to healthier work environments that foster RN satisfaction and reduce RN turnover and vacancy rates in acute care settings. In this article, an innovative approach to reduce nurse turnover and decrease vacancy rates in acute care settings is described. Video feedback with reflection and interactive analysis is an untapped resource for nurse leaders and aspiring nurse leaders in their development of effective leadership skills. This unique method may be an effective leadership strategy for addressing recruitment and retention issues in a diverse workforce.     

Distilling the Antecedents and Enabling Dynamics of Leader Moral Courage: A Framework to Guide Action

Intelligent, robust and courageous nursing leadership is essential in all areas of nursing, including mental health. However, in the nursing leadership literature, the theoretical discourse regarding how leaders recognise the need for action and make the choice to act with moral purpose is currently limited. Little has been written about the cognitions, capabilities and contextual factors that enable leader courage. In particular, the interplay between leader values and actions that are characterised as good or moral remains underexplored in the nursing leadership literature. In this article, through a discursive literature synthesis we seek to distill a more detailed understanding of leader moral courage; specifically, what factors contribute to leaders’ ability to act with moral courage, what factors impede such action, and what factors do leaders need to foster within themselves and others to enable action that is driven by moral courage. From the analysis, we distilled a multi-level framework that identifies a range of individual characteristics and capabilities, and enabling contextual factors that underpin leader moral courage. The framework suggests leader moral courage is more complex than often posited in theories of leadership, as it comprises elements that shape moral thought and conduct. Given the complexity and challenges of nursing work, the framework for moral action derived from our analysis provides insight and suggestions for strengthening individual and group capacity to assist nurse leaders and mental health nurses to act with integrity and courage.     

Leadership, civility, and the 'No Jerks' rule

There are jerks in this world. There are jerks at work. As managers and leaders we are obligated to insure that people have a healthy environment in which they can be nurtured and grow. Patient safety cannot be compromised because we allow jerks to create chaos. This is a serious issue that is very expensive in terms of the toll it takes on people, patients, and the organization. However, there are solutions so we must act. Jerks don't need to be a part of the culture of nursing. Incivility does not need to exist in hospitals and health care facilities. As Carter (1999) notes, the barbarians are truly at the door and this is true of hospitals and of nursing. However, we have the opportunity to change the self-interest behavior of jerks in our communities of caring. That is what leadership is all about.     

Patient safety culture and leadership within Canada's Academic Health Science Centres: towards the development of a collaborative position paper

Currently, the Academy of Canadian Executive Nurses (ACEN) is working with the Association of Canadian Academic Healthcare Organizations (ACAHO) to develop a joint position paper on patient safety cultures and leadership within Academic Health Science Centres (AHSCs). Pressures to improve patient safety within our healthcare system are gaining momentum daily. Because AHSCs in Canada are the key organizations that are positioned regionally and nationally, where service delivery is the platform for the education of future healthcare providers, and where the development of new knowledge and innovation through research occurs, leadership for patient safety logically must emanate from them. As a primer, ACEN provides an overview of current patient safety initiatives in AHSCs to date. In addition, the following six key areas for action are identified to ensure that AHSCs continue to be leaders in delivering quality, safe healthcare in Canada. These include: (1) strategic orientation to safety culture and quality improvement, (2) open and transparent disclosure policies, (3) health human resources integral to ensuring patient safety practices, (4) effective linkages between AHSCs and academic institutions, (5) national patient safety accountability initiatives and (6) collaborative team practice.     

Courage and today's nurse leader

The virtue of courage is often overlooked in distinguishing successful leaders. This void is a reflection of the difficulty in defining just what courage is. Is courage facing risk without fear or overcoming fear to face risk? What are the differences between physical and moral courage? Can leaders develop courage? These and many other questions surround the nature of courage and how it pertains to leadership. It is the author's intent that readers have a general understanding of how courage affects nursing leadership in today's health care environment.     

Structural empowerment and patient safety culture among registered nurses working in adult critical care units

armellino d. , Quinn Griffin m.t. & Fitzpatrick j.j. (2010) Journal of Nursing Management 18, 796–803
Structural empowerment and patient safety culture among registered nurses working in adult critical care units Aim The aim of the present study was to examine the relationship between structural empowerment and patient safety culture among staff level Registered Nurses (RNs) within adult critical care units (ACCU). Background There is literature to support the value of RNs’ structurally empowered work environments and emerging literature towards patient safety culture; the link between empowerment and patient safety culture is being discovered. Methods A sample of 257 RNs, working within adult critical care of a tertiary hospital in the United States, was surveyed. Instruments included a background data sheet, the Conditions of Workplace Effectiveness and the Hospital Survey on Patient Safety Culture. Results Structural empowerment and patient safety culture were significantly correlated. As structural empowerment increased so did the RNs’ perception of patient safety culture. Conclusion To foster patient safety culture, nurse leaders should consider providing structurally empowering work environments for RNs. Implications for nursing management This study contributes to the body of knowledge linking structural empowerment and patient safety culture. Results link structurally empowered RNs and increased patient safety culture, essential elements in delivering efficient, competent, quality care. They inform nursing management of key factors in the nurses’ environment that promote safe patient care environments.     

Moving from a culture of blame to a culture of safety in the nursing home setting

TOPIC: A culture of safety. PURPOSE: To explore the current culture of blame and what organizational elements must be impacted to move toward a culture of safety in the nursing home setting. METHODS: A mixed-method approach incorporating a case study and staff member survey results were used to explicate the organizational elements impacting the current nursing home culture. CONCLUSION: Nurse leaders can create an environment in which every member of the team feels a responsibility and an ability to insure that residents are safe by improving communication and participation in decision making.     

A review of organizational culture instruments for nurse executives

Nurse executives are aware of the complexities of organizational culture. It impacts the nursing work environment and patient care safety and quality. The authors describe several widely available tools that nurse leaders can use to assess organizational culture in the work environment. The psychometric and conceptual strengths and weaknesses of the measures are described and recommendations for use in nursing and patient care administration are provided.     

Transformational leadership can improve workforce competencies

Staffing problems can arise because of poor delegation skills or a failure by leaders to respond appropriately to economic factors and patient demographics. Training dilemmas, meanwhile, can arise because of managers' confusion about what constitutes 'training' and what constitutes 'education', and where responsibility of provision lies, with the consequence that they neglect these activities. This article uses Kouzes and Posner's (2009) transformational leadership model to show how managers can respond. Leaders who challenge budgets, consider new ways of working and engage effectively with the workforce can improve productivity and care, while those who invest in appropriate learning will have a highly trained workforce. The author explains how integration of leadership roles and management functions can lead to innovative problem solving.     

A different age for leadership,part 1: new context,new content

This is Part 1 of a 2-part article on the new and emerging characteristics and elements of leadership for changing, fast-paced organizations. As we leave the 20th century workplace and are increasingly driven by innovation and technological transformation, new roles are demanded from everyone. Leadership expression now calls for a different emphasis and skill set from those that predominated in the past century. The first article focuses on the context of leadership affecting what leaders do and how they must now behave. Part 2 will center on the activities of leadership and the new learning and skill set development that will increasingly be required of leaders in a fundamentally altered work environment.     

A different age for leadership,part 2: new rules,new roles

This is Part 2 of a 2-part article on the new and emerging characteristics and elements of leadership for changing, fast-paced organizations. As we leave the 20th century workplace and are increasingly driven by innovation and technological transformation, new roles are demanded from everyone. Leadership expression now calls for a different emphasis and skill-set from those that predominated in the past. The first article (February 2003) focused on the context of leadership affecting what leaders do and how they must now behave. This article centers on the activities of leadership and the new learning and skill-set development that will increasingly be required of leaders in a fundamentally altered work environment.     

Patient centred leadership in practice

Aim To explore patient centred leadership at every level in an organisation and provide practical examples of how this was demonstrated in an acute tertiary NHS Trust. Background There is a direct relationship between leadership and quality of care. With increasing expansion of their role nurses are in a key position to influence and lead colleagues to improve patient care. Evaluation The Leadership Qualities Framework (NHS Institute of Innovation and Improvement 2006) is used to illustrate the various qualities used by clinical leaders in examples of leadership in practice. Key issue Leadership development with the emphasis on the patient drives improvements in service delivery and patient safety. Conclusion Patient centred leadership is demonstrated when there is support at the top of the organisation. Politically aware nurses make effective patient centred leaders. Leadership development programmes provide staff with opportunities to acquire essential skills and qualities in order to contribute to the vision of the organisation. Implications for nursing management Managers should support staff and take risks in order to empower nurses to implement initiatives which improve patient care. A process of communication using a variety of tools can have a impact on a range of staff. Patient centred leaders are role models for tomorrow’s leaders, their impact has lasting effect and wider implications within an organisation and beyond.     

The development of caring in the perioperative culture: nurse leaders' perspective on the struggle to retain sight of the patient

This article focuses on Swedish nurse leaders and is aimed at achieving a more complete and differentiated understanding of what constitutes caring in the perioperative culture as well as their knowledge and responsibility for the development of caring. Interviews with open-ended questions were conducted with 10 nurse leaders, in which they described their experiences of developing perioperative caring. The interpretation process was based on Gadamer's philosophy of hermeneutics. The findings indicate that developing a perioperative caring culture is a struggle to retain sight of the patient, a process that includes the following 6 phases: (1) when the nurse leaders understood perioperative caring as a process, the nurse's and patient's shared world became obvious to them; (2) safeguarding the patient's position as a unique human being; (3) safeguarding the nurse's welfare by creating a compassionate atmosphere; (4) promoting an idea means never giving up; (5) attaching importance to being trustworthy; and (6) being involved in a dynamic interaction, comprising communion and reciprocity. The most important goal of nursing leadership is to safeguard the welfare of the suffering patient and the relationship between the nurse leader and nursing staff, based on the motive of caritas derived from the idea of humanistic caring.